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Message from the Chair of the openEHR Board

August 10, 2011  |  from: David Ingram

I wrote here some time ago of my forthcoming retirement and our wish and intention, as a Board, to pass the mantle of openEHR to the best possible new leadership and ownership, from October 1st. That time is fast approaching and it is, for me, mainly a period for tidying up and refocusing my personal efforts for the retirement years that now beckon. Forty years of books and papers, collected in a personal journey through health care informatics, have been sifted, distributed to new owners, transferred to new offices, or shredded and disposed of. It jerks one's mind to re-read about the mostly forgotten, day-to-day, ups and downs of the journey; in my case, relatively few take-offs and landings and, for personal reasons, a journey conducted these past two decades as close to home as possible. It confirms one's view and resolve that what remains to be done, and that is very considerable, indeed, is best passed on, with good wishes, to a new generation, able to benefit from but unencumbered by the legacies, some real and valuable, some silly and unnecessary, of the journey one has followed and experienced.

An informal interim steering group consisting of Sam Heard, Dipak Kalra, Thomas Beale, Tony Shannon, Martin van der Meer and I met here in my new office at UCL, a couple of months ago, to discuss a future plan of action, under Sam's leadership. It was a warm and united gathering and I felt immensely proud and appreciative of all of them, each working in their own way for the mission we set for openEHR and renewing their commitment to it, for the future. As we have written, here, we have been seeking new governance and partnership for more than two years. In reality, those who can and wish to commit time and effort, for no return, are rather fewer than those choosing or having to focus more on earning their livelihood, in advising, teaching, researching, developing, selling to and evaluating performance in the field. These in turn are many fewer than those doing the work of delivering services that help healthcare tick and improve.

The Board will be posting the conclusions from this review and seeking input to the next steps in its implementation, very shortly. A new phase of development is needed to consolidate the openEHR specifications and software, address barriers to greater adoption in both health care and industry communities, and place greater emphasis on quality management, ensuring that data and software components can be trusted by end users and care-delivery organizations.

Full details will be published in the manifesto but we envisage, in this phase, that openEHR will:

  • move to an industry-recognised IP license and governance model for software development
  • establish stronger and more open governance around the specifications, ensuring user organisations such as national e-health programmes can proceed safely, with their interests protected
  • define a governance and IP model for clinical models (archetypes) so they can be used in both industry and national programmes

I am confident that this manifesto will go a long way to respond to the many points that have been made to us, openly on the lists and in private correspondence. We know we have to use the IP vested in the Foundation for good ends, faithful to the mission we set for it at its outset.

To tidy this hand-over, Sam and I have worked with a very experienced firm of IP lawyers to make completely watertight and formalise the transfer from UCL and Ocean Informatics of the core elements of openEHR architecture IP - including specifications, documentation, web resources and trademark to the openEHR Foundation. We have not included any of the open-source software we have developed, as of now, as our advice is that this is best dealt with by using the Apache 2 license.These assignments will be made public. I will retain the original certificate of incorporation, as a personal keep-sake, above my new desk, in my new attic room above CHIME at UCL. Dipak is now very much in command as my much appreciated successor as Director of CHIME, downstairs. We will also be announcing shortly three new appointments to the openEHR Board and a new Advisory Board for its transition into new partnerships and governance.

My role in openEHR has been very much one of mentorship, enablement and peace-making, for a number of years, now. In financial terms, with the full support of UCL senior management, I have been able to put six figure sums of personal effort and resource, in cash, and seven figure sums, in kind, into supporting the openEHR mission. It is not easy to manage the sometimes conflicting interests implicit in wearing multiple hats and so, because it was only Dipak and me that had the luxury of taking such a position, we have been cautious to avoid personal financial interest in anything related to openEHR - quite the reverse. But, as I retire from these responsibilities, I have to think about supporting myself and paying back to UCL some of what it has invested in me. So I am now starting new UCL companies, spinning out aspects of research I have created, led and enabled, for twenty years. Accordingly, I am retiring from the openEHR Foundation Board at the end of September, delighted though to continue as President, a position Sam and Dipak, my founding co-directors, have asked me to assume. openEHR has been a lot of my life and I hope to continue constructively engaged with it, as it evolves into the future.

I would have to write a book to do justice to openEHR's origins and development, as well as to give my personal assessment of some of the injustices with which it has been saddled, by a few, who, despite the invocation in joining the lists, to work constructively for its mission, have registered and appeared there largely, it sometimes seems, to oppose that mission, for reasons they alone can best speak for. I'm not sure I want to write that book and am doubtful anyone would want to read it! Let me just say that it is noticeable from the logs of who accesses openEHR resources that it is very widely followed, and that some who are sometimes articulate or active in criticising it, or are working quietly creating, sometimes proprietary products and alternatives, or in related businesses, are among those who seem to download from it and reapply it, most. No surprise there, of course, and I would be the last to pursue such perceived injustice as I think it is both inevitable, and also, ultimately, strengthening of the mission that openEHR has always existed to support.

Speaking personally, openEHR has given me a chance to create, nurture and work very closely with a great team of colleagues, who have participated in and connected themselves to the wider community of my Department, CHIME, here at UCL. I remember meeting Sam for the first time, then a General Practice principal and lecturer at my first Medical School, St Barthomew's Medical College in the City of London. I remember Dipak joining the early GEHR team that Sam had invited me to lead. Both of them have been the greatest and most supportive colleagues anyone could hope for, and I owe them huge debts of gratitude.Dipak has become a natural leader of so much that has evolved from that work and era, in CEN and ISO, and EuroRec. I remember recruiting David Lloyd from his NHS IT post, with huge experience in neurophysiological signal processing and immense team playing and leading qualities, into the group. I remember recruiting Thomas to the team, on the advice of my close colleague, Jo Milan, who was the presiding genius and creator, over twenty years and more, of the finest clinical systems ever developed and used in the NHS. I remember the highly creative, and indeed hoped for, rumpus that Thomas joining us brought to the GEHR project - times haven't changed... I remember the close friendships of many others still active in the field, over very many years - John Williams and Martin Severs at the Royal College of Physicians, and Alan Rector and Chris Taylor in EU and UK research projects and academic fora. Chris, Jo and I met when we served together on the Hospital Physicists' Association Computer Topic Group in about 1971.

We have all done a lot of living together, the essence of good and satisfying work. But there's a huge amount still to do. The physicist Max Born rather poetically once described science as the opening of windows onto the night sky, increasing our view of the unknown. Human kind doesn't like the unknown and tends to respond with ritual and resistance to the challenges it brings. One should not regret such challenges, they are intrinsic to any worthwhile human and social progress.

In relinquishing my role, I have three things to recommend and ask, here, based on my take of the state we're in:

1. Do keep focused on practical implementation and experimental innovation.

These are essential if we desire defensible statements about real world clinical requirements and how to work effectively to meet them and thereby make a difference to health informatics, which still remains a very immature field of endeavour.

2. Don't succumb to what Freud called the narcissism of small difference - overplaying differences between like approaches or concerns, for personal, reputational or other advantage.

It doesn't surprise me that two important threads of development, each building from the seminal work of the GEHR project - into openEHR and ISO 13606 - should have strong and committed adherents. I think that's good and healthy. It does surprise me, though, that some apparently believe that they are antithetical in approach or substance - put simply, please give me chapter and verse. They were umbilically joined, in their origins and in their formulation, as for example through the 1.4 version of the openEHR ADL language, developed by Thomas Beale, when he and Sam had moved on to create Ocean Informatics, back in Australia, but deeper than that in all that David Lloyd and Dipak Kalra brought from GEHR and CHIME into the reference model proposed and agreed on in the CEN and ISO Task Forces. When schism seemed to have arisen, I wrote a paper setting out the origins of the two, and my approach to them, as someone who had committed a huge amount of personal and institutional effort and resource into them both. I sent this just to people then discussing the issues. As the concern still seems to be around, I shall post that account on the openEHR web site, now. It's an issue I feel some responsibility to clarify openly, now, for a number of reasons. Among them, as a physicist, I have often said that the concept of unique models for the EHR information domain seems silly. What we need is models that work, clearly anchored to requirements that adequately represent reality. Making choices among models, which have to be made, requires a range of candidate models to be expressed and communicated such that we can learn about them and how well they can add value to the domain they serve, as opposed to the reputational, institutional or financial well-being of their proponents.

3. Do maintain multi-disciplinarity and openness, but cede leadership to the new generation of clinical leaders.

When I was first appointed as a new-fangled lecturer in medical computing and physics, many moons ago, I had to endure the ridicule and condescension of Deans and doctors, as to what on earth I was doing there - it didn't help that I wasn't too sure, myself. But, as well, I enjoyed the patronage and support of some who were able to look ahead (in a pre-Hounsfield, post Crick and Watson but pre-DNA sequenced world ) to how IT and health services might respond and co-evolve, in relation to the upcoming period of scientific, social and technological transformation of medical science, and the equally immense challenges of changing demography and sense of global health mission.

It was always apparent to me that the evolving sense of what medicine is, and how it is communicated among patients and practitioners, was the central issue in charting a pathway towards understanding which developments were core to the mission of computation in medicine and which were, at best, a side-show of technological virtuosity or even, sometimes, vanity. It matters that lawyers, anthropologists, clinicians, mathematicians, biologists, engineers, physicists, even, and many others - of academic discipline, clinical and patient grouping, and none - are able to rub shoulders and work out, experimentally, how to formulate and deliver mission in response to the complex socio-technical challenge of health informatics. Health Informatics needs to be like that and needs to build community across all disciplines and groups. The imperative to communicate and explain health informatics is why I, personally, believe in the open movements: Open Source, as I have seen the damage and confusion caused by mismatch of the claim and reality of software; and Open Access for publication, through chairing the Academic Advisory Board for UK PubMedCentral resources.

In closing, please forgive the end-of-term, even fin de siècle tone of all this. I realise it's my end of term, not anyone else's. I'd like to add that for me, one of the great privileges of academic life, in a great world institution like UCL, is the opportunity to work with and enable the next generation of talent, equipped to learn from past endeavour and insight and take the next steps forward. There is, as always, a motivated and able new generation of people becoming engaged, clinically and technically, with what started as the GEHR architecture and led on to derivative work now formulated, very comprehensively, in the openEHR architecture, in the 13606 standard, and in much more to come, I'm sure. I hope there will be a growing convergence of this talented community, throwing off the residue of growing pains and creating mutually respectful and supportive new community for the good of EHR and wider new Health Informatics initiatives. A great deal needs to be done but we now have sufficient achievement that it is completely unnecessary and illogical, and indeed inadvisable, to enter a further cycle of invention and collapse, such as has been, to a large extent fostered in ill-prepared and fuelled initiatives, about five times over, in my career of experience. openEHR needs to offer what it can and play its part to make sure that doesn't happen.

The wastefulness of the field, at government levels, has led me to admire the Fred Brooks approach, of the mythical man-month. I tend to think we will finally gain traction only when there is a tenth of the money being spent, and systems are, in some equivalent sense, ten times more agile in terms of necessary continuing evolution and change, and thus ten times more sustainable. That sounds a bit like 20-20 vision- in this case 10-10-10 vision.

Finally, and most importantly, my best wishes and thanks to all the brave and determined implementers, working so hard to make a difference in the field. This marks the end of my full-time innings, among you and in support of all of you.


David Ingram


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